There are two forms of birth control. Non-hormonal and hormonal methods. Non-hormonal birth control is any option that does not have a hormone in it. Options include the copper IUD and barrier methods like the condom, cervical cap, diaphragm, sponge and sterilization. Rhythm or calendar methods where you’re tracking cycles and assessing cervicales fluids need to be tracked vigilantly and many will choose to still use an additional method if cycles are unpredictable.
Breastfeeding itself has also historically been considered its own form of birth control. Lactation amenorrhea is nature’s natural family planning to help space out babies. If you are exclusively breastfeeding, no bottles no pacifiers no pumping, and baby is still nursing frequently day and night, often sleeping close to or co-sleeping with breastfeeding parent, where there is no vaginal spotting or a period hasn’t returned yet and baby is under 6 months of age, this form is considered >95% effective to keep you from getting pregnant again. While this is the general rule of thumb, every single criteria needs to be met in order for it to be effective. And even if this is being followed to the letter, some may still cycle again and can become pregnant before a period returns. I’m of the anecdotal opinion that there are many modern influences on why this method doesn’t always work. Prior history of HBC, maternal age, modern diet and lifestyle, may not allow everybody to be able to experience this form of birth control. On the other hand, there is also a small population that never gets a period the entire time they breastfeed and may actually need to wean in order to get pregnant again. This method of bc is not one size fits all and needs to be counseled as such. It is possible to have several light periods without ovulating, giving you a heads up that another form of bc is needed to prevent pregnancy, but it is also possible to ovulate and get pregnant before you have a first postpartum period.
In terms of hormone based birth control, in a nut shell:
- Hormonal Birth Control (HBC) comes in 6 different delivery systems.
- Any HBC runs the risk of decreasing your milk supply. So you’ll want to be careful with the method you’re choosing.
- The hormone level of each brand in each type of HBC will have its own amount of hormone and they are not equal. So do your research when selecting any HBC, even if you’ve used a particular method prior to your breastfeeding days.
All types of HBC prevent pregnancy effectively but the best method for you will be the one that suits your lifestyle and needs. The most effective HBC will also support any goals you personally have related to breastfeeding.
Hormonal methods of birth control contain either progestin or a combination of both progestin and estrogen. Hormonal birth control options include the pull, the intrauterine device (IUD), the shot, the implant, the ring and the patch. These methods of birth control have high rates of efficacy, but if you choose a method that is difficult for you to use correctly, it could lead to unintended pregnancy. Certain methods also carry a higher risk of decreasing milk supply
All HBC works to prevent pregnancy by preventing ovulation or thickening cervical mucus to prevent implantation of an already fertilized egg. Many do both.
The best birth controL is one that works for for each individual’s lifestyle, that can be used correctly and consistently. Knowing what’s available and the risks and benefits of each method can help guide the best choice for your family. In the event you see an impact on your breast milk and need to switch forms to reach your goals, there are also many options. Please also note that hormone based contraceptives are not considered safe for ALL to take and you will want to discuss your unique medical history with your healthcare provider when making any decision about what you are putting in your body.
A small amount of the synthetic hormones in contraceptives will enter your milk and be passed to your baby. There is no evidence in the research that this is harmful to your baby. Some babies younger than 6 weeks may have difficulty metabolizing the hormones and for this reason it is not recommended to start using HBC until your baby is older than at least 6 weeks. Some report after they start taking HBC they notice an increase in fussiness in their babies and many of these same parents report an improvement in the fussiness when they change their method of birth control.
Also keep in mind that no form of hormonal contraception offers protection from sexually transmitted infections (STIs)—but using a condom with a hormonal birth control even further reduces your risk for pregnancy while also protecting from STIs.
Let’s take a look at different forms of hormonal birth control, how they are delivered and how effective they are.
Oral contraceptives are also called “the pill.” Birth control pills have been in use since the 1960s are the most common form of hormonal contraception in the United States. There are three types of pills with different combinations of hormones. The first is the cyclic combination oral contraceptive (COC). People who use this pill as prescribed have monthly bleeding that mimics a monthly period. The second type is the extended use COC pill. When taken as directed, a person experiences less menstrual-like bleeding. This method tricks your body into thinking it’s already pregnant so it doesn’t release an egg to be fertilized. There’s also the progestin-only pill (POP), which is estrogen-free and is often referred to as “the mini pill”.
The benefits of the pill include it’s rapid reversibility (cycles return within a few months), regulation of menstrual bleeding, decreased menstrual blood loss, decreased menstrual pain, decrease in frequency of menstrual migraine and decreased endometriosis symptoms. Because the hormones in the pill suppress ovulation, its use is also associated with decreased premenstrual syndrome (PMS), decreased ovarian cysts, decreased risk of ovarian cancer and decreased risk of fibrocystic breast changes and cysts.
Birth control pills must be taken daily to achieve the highest level of efficacy. They also have increased potency when taken at the same time every day to maintain hormone levels consistent across time. Research shows that more than half of people using the pill forget to take one or more each month. Both the COC and extended COC pills have estrogen, the hormone that raises during pregnancy and is in opposition to prolactin and oxytocin, the hormones responsible for making and releasing milk. Taking either of these options will drastically drop your milk supply and are not preferred when breastfeeding is the goal. Progestin only pills, called the mini pill, is considered safe while breastfeeding and has the least risk of dropping milk supply. This is the preferred method of contraception while breastfeeding. While the limited research that is out there shows it holds a minimal risk of dropping supply, every body responds differently to hormones, and I have seen some people drastically drop their supply even on the mini pill. The perk of this methods is If you notice a drop in supply you can stop taking the pill and your supply should rebound in the same time frame it took to see it drop. So if you were on the pill for one cycle it will usually only take one cycle to rebound. Many people see no difference in their supply when taking the mini pill but this is why we call it risk assessment.
The patch is similar to the pill in that it contains estrogen and progesterone. Instead of taking a pill every day, however, the patch is made of thin plastic that is placed on the skin of the arm, abdomen, buttocks or upper torso and delivers hormones through the skin. The patch should be placed on clean, dry skin and needs to be replaced weekly. Typically, the patch is used for three consecutive weeks, followed by one week during which no patch is worn in order for menstruation to happen. Benefits of the patch include the convenience of once-a-week dosing and a rapid return to fertility for those who stop the method to become pregnant. Some reported side effects of the patch include skin reactions, breast discomfort, headache and nausea. Because of the high levels of estrogen and progesterone, this method is also not preferred while breastfeeding as it runs a high risk of significantly decreasing breast milk supply.
The ring delivers estrogen and progesterone through a circular piece of plastic that’s vaginally placed. The ring is inserted and often left inside the vagina for three weeks, followed by one week during which no ring is used to facilitate menstruation. Some advantages of the ring include rapid return to fertility when pregnancy is desired, convenience of weekly insertion, and the ability to remove it for a brief amount of time (3 hours) without compromising efficacy. Some ring users report vaginal discomfort, and others experience nausea, breast tenderness, or changes in libido. As with some other hormonal contraceptives there may be a risk of blood clots with the ring, but more research is needed. Because of the high levels of estrogen and progesterone, this method is not preferred while breastfeeding as it runs a high risk of significantly decreasing your supply.
The shot is also called the injectable contraceptive. A commonly used version of this contraceptive contains only progestin , no estrogen. and is administered every three months. The shot is reversible, but a return to fertility may be delayed until the effect of the last injection wears off. Because the effects of the shot can last up to 3 months, if you are one of the people that does experience a drop in milk supply with any progestin based HBC, you do run the risk of losing the supply and not being able to bring it back up until the effects of the shot wears off. Which means you may need to supplement until the shot wears off and you run the risk of not being able to bring back supply as that is a signficinat amount of time to have a lowered overall supply.
Some people like the shot because it is available without estrogen and is only taken every one to three months depending on the brand. Some other benefits include absent or light bleeding, decreased cramps and PMS symptoms, reduced endometriosis pain and decreased risk for pelvic inflammatory disease (PID) and endometrial and ovarian cancer.
The shot has some potential disadvantages. Bleeding can become unpredictable for some while others may find they don’t bleed at all. There is also a higher correlation of people who get the shot and see and increase in weight, although the research isn’t sure why. More research is needed to determine whether and how the shot impacts mood (people interested in this method but worried about the role of hormonal contraception in depressive symptoms could mention this to their healthcare provider). This is especially compounded in the postpartum period when there is a higher risk of PPD/PPA. People who use the shot long-term can experience a loss in bone density, but it’s generally reversible. The biggest challenge with the shot and breastfeeding is once you’ve been given the shot you can take it back. The hormones are in your system. If you see a drop in your supply you won’t be able to do much about it until the shot wears off. There would be a few, extreme interventions such as herbs, medications, and additional feeding and pumping that may help, but supply is not guaranteed to rebound from this type of drop.
The hormonal implant is the most effective form of hormonal birth control. The implant is a thin rod that is inserted under the skin in the upper arm. It lasts for three years, at which point you can return to your health care provider to have a new rod implanted. The implant is progesterone-only and contains no estrogen. There are several advantages to this type of method: you never need to generate to do anything, its discreet, decreased menstrual pain and rapid reversibility. Because it’s effective for three years, the implant is also cost effective. In research studies, fewer than 20 percent of people have the implant removed early because of side effects.
Insertion of the implant is an in-office procedure that causes a small percentage with this type of HBC to experience some swelling, bruising, and pain. Removal of the implant is also an in-office procedure and usually takes just a few minutes. Some disadvantages of the implant include the possibility of unpredictable bleeding, headache, weight gain, acne and breast pain. Studies are in conflict for whether it lowers libido or improves sexual function. Because it is progestin only, it does have less of a chance of decreasing your milk supply. BUT if you are one that does see a drop in supply with any HBC and you see a drop in supply from this method, only removal of the implant will help increase supply again. Because of this, you might want to trail the effects of progestin only pills before trying this semi permeant method of contraception.
The IUD is a small T-shaped implant placed inside the uterus. There are two types of IUDS: copper, which doesn’t have hormones, and hormonal. It must be placed by a healthcare provider in an in-office procedure. Some OBs may push for placement of an IUD at your 6 week postpartum appointment. This is because the cervix often hasn’t fully closed since delivery so it is easier for your practitioner to place. The IUD is highly effective. It doesn’t contain estrogen, is a one time placement that you can forget and not need to have placed multiple times, discreet, rapidly reversible, long lasting and has high rates of satisfaction among those who have one placed. Hormonal IUDs come with differing doses of hormones and the length of their use varies from three to seven years based on each brand. This is important to consider. The higher the level of hormone in the IUD, the higher the risk it will cause a drop in your supply. The Mirena and Liletta have 52mg and the highest amount of hormone. The Kyleena has 19.5mg and Skla has 13.5mg. The paraguard, which is made of copper has 0 hormones and will not impact milk supply but carries the same other risks of IUDs. If you see a supply drop, there is not much you can do to regain that milk as this is reproductive hormones impacting breast milk hormones.
Some potential disadvantages include unpredictable changes in period cycles, cramping at the time of insertion, and some concerns about weight gain. In rare cases, pelvic infection can happen after insertion. Occasionally they have also “fallen out,” or people have pulled them out accidentally. There is also a rare but possible chance that it will perforate (poke through) the wall of the uterus. If the IUD is the culprit for decreasing your milk supply, depending on your breastfeeding goals and how significant the drop is, some will consider removing the IUD.
There is no way to predict how your individual body will respond to a HBC, even if you used it prior. Depending on the importance of the breastfeeding goal vs risk of pregnancy, I always counsel my patients to consider trying a round or two of the mini pill prior to IUD insertion. If they do notice a drop in supply, stopping the pill and using a different method of non hormonal contraceptives may help them reach their goal for breastfeeding. Other families will assess the risk of pregnancy vs breastfeeding vs formula and if there is a supply drop, supplement with formula to whatever level is needed. This decision is one that only you and your partner can make and the options need to be weighed based on your unique lifestyle, family planning and breastfeeding goals.
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